Confidential Financial Statement

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UCLA
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G r a d u a t e D i v i s i o n
CONFIDENTIAL FINANCIAL STATEMENT
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Complete this form only if you will need an I-20 Certificate of Eligibility for an F-1 student visa or an IAP-66 Certificate of
Eligibility for a J-1 exchange visitor visa. While there are no restrictions on the source of funds for applicants for F-1 visas,
applicants for J-1 visas must show funds coming from specific sources (e.g., applicant’s home government,
international organizations or UCLA). Complete both sides of this form carefully and accurately. Print or type all
information except signatures. Signatures and bank stamps must be included to validate the form.
• A P P L I C A N T I N F O R M A T I O N • (Give your name exactly as it appears on the UCLA Application for Graduate Admission)
Family Name _________________________________________ First Name (only) _______________________________
UCLA ID number ______________________________________ Date of Birth ___________________________________
(if known) month/day/year
•SOURCE OF FUNDS• (Indicate in U.S. Dollars) Complete Sections A, B, and C as they apply to you.
Section A Family or Individual Sponsor’s Funds
Amount of funds to be provided by family member or sponsor U.S.$
Sponsor’s Guarantee
“I ____________________________________________________ , ____________________________________ guarantee
(signature) (please print full name)
that the funds indicated in Section A will be available for the applicant listed for the first year of education at
UCLA.”
Address _______________________________________________ Occupation____________________________________
______________________________________________________ Relationship to applicant _______________________
Bank Verification
“This is to certify that the sponsor listed in Section A is financially capable of meeting his/her commitment as
indicated in Section A and if the funds are outside the U.S., the government has no restrictions regarding the
release of funds.” Bank Stamp
Signature of Bank Official _______________________________
Title _______________________ Date ____________________
Address _______________________________________________
Section B Sponsoring Organization, Firm or Government

Name of sponsoring party _____________________________ Amount to be provided U.S.$ _________
Attach an original signed copy of terms of support that specifies the amounts provided for tuition and/or living
expenses and year/s covered by the award.
Section C Personal Funds

Amount of personal funds you will have available (not otherwise indicated on this form) U.S.$ _________
“This is to certify that the person named above, who is applying for graduate admission at UCLA, has on account
the amount indicated in Section C and that if the funds are outside of the U.S., the government has no restrictions
regarding the release of funds.” Bank Stamp
Signature of Bank Official ______________________________
Title _______________________ Date ____________________
Address _______________________________________________
TOTAL AMOUNT OF FUNDING FROM ALL SOURCES (total of sections a, b, and c) U.S.$ 0.00
_________
Next Page
You must complete and sign the other side of this form.
F UCLA F Graduate Admissions/Student & Academic Affairs F Box 951428 F 405 Hilgard Avenue F Los An geles, CA 90095-1428 F
•ADDITIONAL FINANCIAL INFORMATION•
While attending UCLA will you live free of charge with friends or relatives? ___ yes ____ no
If yes, the responsible person must sign the statement below.
“I ____________________________________________________ , ____________________________________ guarantee
(signature) (please print full name)
that room and board will be provided by me at no cost to the above named applicant.”
Address Occupation ______________________
Relationship to applicant ______________________
•RESIDENCY INFORMATION•
City of Birth____________________________________________ Country of Birth
Country of Citizenship Visa you now have (if applicable)
Visa you expect to receive
Mailing Address
•DEPENDENTS•
L I S T A L L D E P E N D E N T S W H O W I L L B E A C C O M P A N YI N G Y O U T O T H E U . S . T HIS
INFORMATION WILL BE INCLUDED ON THE CERTIFICATE OF ELIGIBILITY AND WILL B E
NEEDED TO OBTAIN VIS AS FOR THEM.
Name Date of Birth Country of Citizenship Relationship to you
•SIGNATURE OF APPLICANT•
Please read the statement below and sign:
“I certify that I have considered each question carefully and that my statements are true and complete to the best
of my knowledge. Further, I understand that enrollment in the University of California may be denied if any
information is found to be incomplete or inaccurate. If any change in my financial situation occurs, I will notify
Graduate Admissions/Student & Academic Affairs at once.”
Signature of Applicant ________________________________________________________ Date __________________
First Page
07/99

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Section B Sponsoring Organization, Firm or Government

Section C Personal Funds

Name Date of Birth Country of Citizenship Relationship to you

Signature of Applicant ______________________________________ Date

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